ASHA: God of Many Hopes and The Beast of All Burdens

The eastern state of Odisha has the fourth highest number of fatalities due to conflict among Indian states – after West Bengal, Chhattisgarh and Jharkhand. Within Odisha, it is Koraput district that has witnessed the highest number of such deaths. In 2010, it witnessed at least 43 such fatalities.

In such a situation, imagine the plight of poor communities living in the hinterland when it comes to accessing health care. People here are sometimes unable to get treatment for even grievously ill family members, either because health personnel refuse to come fearing attack, or because there is no source of transportation because of an outbreak of violence or a ‘bandh’ (strike) call.

In these extremely disturbed conditions, where there is no doctor, where there is constant fear caused by the endless cycle of Maoist violence and state reprisal, it is the Accredited Social Health Activists (ASHAs) who have lived up to their name – ‘asha’ or hope. In fact, Nobel Laureate Amartya Sen recently observed that ASHAs are the “God of Many Hopes and the Beast of All Burdens”.

Many in Koraput vouch for the life-saving abilities of the ASHAs. Take Barti Jani, 23, of Mademgandi village in Potangi block. It is because of an ASHA, Moti Jani, that she is alive today. “I owe my life to Moti didi,” states the young woman. It was Moti who had her taken to a hospital at two o’clock on a stormy night.

Recalls Barti, “I was three months pregnant and suddenly experienced a severe pain in my lower abdomen. The hospital at Potangi is about seven kilometres from here. My husband asked neighbours to help, but nobody came forward because people don’t leave their homes at night fearing Maoist attacks. At that point, Moti didi – who lives in another hamlet two kilometres away – arrived. She convinced a villager to lend us his rickshaw. With my husband pulling it, we could reach the hospital at around 4.30 am. I was admitted and operated upon immediately.”

Dr N.K. Kar of Potangi Hospital, too, is all praise for Moti, “Barti had an ectopic pregnancy. The tube had ruptured and she was bleeding internally. If she hadn’t been brought on time, we couldn’t have saved her. The whole credit goes to ASHA Moti Jani, who showed immense courage in bringing her to hospital in a situation in which people are too scared to travel even during the day, forget about night.”

In nearby Phulpadar village, there is a young man – Sarbeswar Muduli – who is also full of gratitude. Phulpadar is around 18 kilometres from the headquarters of Koraput district, and is one of the most inaccessible areas. One would need to embark upon a journey of 15 kilometres by a vehicle and cover an additional three kilometres on foot. Three years ago, Sarbeswar had lost his wife during childbirth – he hadn’t made it to the hospital in time. When he married again, he made sure his new wife’s pregnancy was supervised by “ASHA didi, Minati Gauda”. It was she who took the young couple to the Koraput district hospital where the expectant woman had a safe delivery.

Everywhere in this tribal district there are many stories like these, but the ASHAs themselves do their work overcoming many problems. Take Sabitri Bisoyee, 35, who became an ASHA three years ago. She covers 13 villages, a territory of 12-15 square kilometres in forested terrain. And she does this on foot. “Most of the time, there is no transportation available and the on-going conflict between the state and extremists has only made things worse,” she says. The government had promised cycles and mobile phones to them but so far they haven’t come.

Most ASHAs themselves come from poor families and are in dire need of a regular income. Parvati Dora, 32, who has studied up to Class Six, describes her situation, “I belong to a very poor family and it is difficult for us to live on my elderly father’s wages. It was to help out that I became an ASHA. We got trained to do many things, like collecting blood samples, distributing medicines, and providing general primary health care.”

She says she tries hard to carry on with her responsibilities, despite the fear factor looming large, “We always try to save the patient’s life.” But this is often difficult given the poor facilities in primary health centres and the general absence of doctors. Many ASHAs report they feel “helpless”.

But women like Parvati are, in fact, shouldering the responsibility of delivering healthcare here. Dr R.N. Das, the chief district medical officer of Koraput agrees that these women are working hard in really adverse conditions. “It is difficult to get trained doctors, and at least 30 to 40 per cent of government medical posts lie vacant because no one wants to come here to work.”

And yet, despite their undoubted importance, the issue of a fair compensation for them is hardly discussed. About 70 per cent of the total income of ASHAs is earned through the Janani Suraksha Yojana (Safe Motherhood Scheme), under which they are required to bring pregnant women to health institutions for their deliveries. They receive Rs 600 (US$1=Rs 44) per delivery, including Rs 250 for transportation. However, there are no incentives for ante and post natal work.

According to the report of the Orissa Technical and Management Support Team (TMST), the ASHAs of the under-serviced, relatively inaccessible KBK (Koraput-Bolangir-Kalahandi) region are paid 25 per cent less than those elsewhere in the state. According to its calculations, the potential income of an ASHA here is Rs 1,800. However, on an average, she earns Rs 954, and actually receives only Rs 721.

“Payments to ASHAs are incentive based, but sometimes we can’t even get the Rs 100 we are supposed to be paid as incentive per delivery. In all, I earn about Rs 700 to Rs 800 a month,” says Sabitri, who has to help support a family of six.

Bhanumati Gadaba, an ASHA of Maliguda village in the district, explains the lags, “We are often paid in bulk for several months of work. There are no written statements for payments made, which means we are unable to verify whether the amount we get is correct. There is also no system to reimburse us if there are errors.”

ASHAs also lack job security since they don’t exist on the rolls. In fact, as Sabitri points out, even ASHAs with 10 years of experience are yet to be regularised. Bhanumati adds, “I know that other health providers, like auxiliary nursing midwives, also face problems, but we can’t forget that they are permanent staff on the government’s pay rolls and enjoy a regular salary, while we don’t.”

A senior consultant and ASHA coordinator for the National Rural Health Mission, Sushant Nayak, based in Bhubaneswar, is very aware of these challenges. “Right now in Odisha we have more than 40,000 ASHAs in place. In Koraput alone there are over 1,400. Usually one ASHA is expected to cover about 1,000 people. However, in the difficult regions, we are in the process of ensuring that one ASHA covers 100 people so that their work load is reduced.”

But social activist C.H. Shantakar believes that more should be done. “Additional incentives should be made available to these women, so that they can play their designated role as community mobilisers and service providers. They also need skill enhancement so that they can conduct themselves with greater confidence.”

Watching ASHAs working in the field at close quarters helped me realise the import of Amartya Sen’s words. These women do indeed play the role of God. They need to be accorded the recognition and compensation they deserve.

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